Questions 51-100

Question 1

100. When assessing the nutritional status and growth of a full-term infant, it is useful to know that birth weight is expected to be regained within

A) 5 days
B) 14 days
C) 21 days
D) 28 days

Answer 1

Item 100
ANSWER: B
A helpful guideline for assessing normal growth of a full-term healthy infant is that birth weight should be regained within 14 days. Other useful guidelines for healthy term infants include an average weight gain of 30 grams (1 oz) per day for the first month of life and doubling of birth weight between 4 and 5 months of age.

Question 2

99. A 75-year-old male reports that his handwriting seems more “cramped,” he has started shuffling more as he walks, and he has been experiencing some difficulty turning over in bed, rising from a chair, and opening jars. He also reports increasing body stiffness and a resting tremor in his hand.

Given the stage of his disease, which one of the following options for initial medical management is supported by the best evidence?

A) Amantadine
B) Bromocriptine (Parlodel)
C) Benztropine
D) Carbidopa/levodopa (Sinemet)
E) Entacapone (Comtan)

Answer 2

Item 99
ANSWER: D
All of the drugs listed are used to treat motor symptoms in patients with Parkinson’s disease. However, the best evidence supports the use of carbidopa/levodopa, non-ergot dopamine agonists such as pramipexole or ropinirole, or monoamine oxidase-B inhibitors such as selegiline or rasagiline for initial management of patients with early disease (SOR A).

Question 3

98. An 85-year-old male smoker presents with a 6-day history of subacute abdominal pain. He reports nausea without vomiting, and no change in stool. His past medical history includes coronary artery disease, peripheral vascular disease, and a cholecystectomy. The physical examination reveals moderate periumbilical tenderness without guarding or rebound.

Laboratory Findings

WBCs. . . . . . . . . . . . . . . . . . . . . . 20,000/mm3 (N4500–10,800)
Segmentedneutrophils. . . . . . . 82%
Bands. . . . . . . . . . . . . . . . . . . . . . 7%
Chemistrypanel. . . . . . . . . . . . . . normal
Urinalysis. . . . . . . . . . . . . . . . . . . normal
Amylase. . . . . . . . . . . . . . . . . . . . 180U/L(N less than 140) Lipase . . . . . . . . . . . . . . . . . . . . . normal
Lactic acid . . . . . . . . . . . . . . . . . . 3.8mmol/L(N0.5–2.2)

Abdominal CT reveals air within the wall of dilated loops of small bowel.

Which one of the following is the most likely diagnosis?

A) Acute cholangitis secondary to a common duct stone
B) Acute diverticulitis
C) Acute mesenteric ischemia
D) Acute pancreatitis
E) Acute appendicitis

Answer 3

Item 98
ANSWER: C
Mesenteric ischemia presents with pain disproportionate to the findings on examination, often with nausea, vomiting, or diarrhea. Air within the wall of dilated loops of small bowel (pneumatosis intestinalis) and evidence of acidosis also suggest bowel ischemia. Cholangitis most likely would be associated with a more substantial elevation of the amylase and/or lipase levels, as well as elevated bilirubin and/or alkaline phosphatase levels. Pancreatitis would also be associated with higher amylase and/or lipase levels.

Acute appendicitis often has a vague presentation in older patients, presenting without fever and not localizing to the right lower quadrant as it does in younger patients. However, the leukocytosis is usually not as dramatic as in this case, there is usually no elevation of the amylase or lipase levels, and imaging does not show air within the small bowel.

Question 4

97. An 18-month-old male with a history of prematurity at 36 weeks gestation but no baseline lung disease is brought to the emergency department with a fever of 38.3°C (100.9°F), rhinorrhea, cough, wheezing, mild tachypnea, and an oxygen saturation of 88%. A chest radiograph reveals perihilar infiltrates, and a nasal swab is positive for respiratory syncytial virus (RSV) antigen.
    Which one of the following management options has evidence of benefit for this patient?
    A) Aerosolized ribavirin
    B) Supplemental oxygen
    C) Intravenous corticosteroids
    D) Macrolide antibiotics

Answer 4

Item 97
ANSWER: B
Respiratory syncytial virus (RSV) bronchiolitis is responsible for approximately 2.1 million health care encounters annually in the United States. The child in this case has a typical presentation of RSV bronchiolitis. The diagnosis can be made clinically, although specific testing for RSV is often used in the hospital setting to segregate RSV-infected patients from others. Management is primarily supportive, especially including maintenance of hydration and oxygenation. Bronchodilators, corticosteroids, and antiviral agents do not have a significant impact on symptoms or the disease course. Ribavirin is not recommended for routine use due to its expense, conflicting data on effectiveness, and potential toxicity to exposed health care workers. Antibiotics are of no benefit in the absence of bacterial superinfection.

Question 5

96. An 85-year-old male admitted to the hospital for shortness of breath is diagnosed with terminal lung cancer. He decides he would like to receive home hospice care. Over the course of his hospitalization he becomes increasingly confused and forgets where he is and why he is there. He appears depressed with a flat affect. He repeatedly tries to get out of bed and pulls at his IV line and catheter.

Which one of the following medications would be most appropriate for treating these symptoms?

A) Haloperidol
B) Nortriptyline (Pamelor)
C) Pentobarbital (Nembutal)
D) Lorazepam (Ativan)
E) Mirtazapine (Remeron)

Answer 5

Item 96
ANSWER: A
This patient is showing signs of delirium, which is common in hospice patients. Delirium should be considered in anyone with disturbances of cognitive function, altered attention, fluctuating consciousness, or acute agitation. The mainstay of management is the diagnosis and treatment of any conditions that may cause delirium. Medications that may cause delirium should be discontinued or reduced if possible. Antipsychotic medications are the drug of choice to improve delirium. Central nervous system depressants such as benzodiazepines and barbiturates should be avoided because they can make delirium worse. Nortriptyline has anticholinergic side effects and can also cause delirium. Mirtazapine would not be helpful for treating delirium.

Question 6

95. A 37-year-old male complains of severe headaches that typically involve his right eye, and often cause the eye to tear. The headaches occur at about the same time each day and recur for several days in a row before remitting. He reports that he is currently experiencing a third episode of these headaches.

Which one of the following therapies will help prevent future recurrences of this patient’s headaches?

A) Oxygen
B) Sumatriptan (Imitrex)
C) Lithium
D) Verapamil (Calan, Verelan)

Answer 6

Item 95
ANSWER: D
This patient suffers from cluster headaches. Both verapamil and lithium are the mainstays of treatment for chronic cluster headaches, but of the options listed, only verapamil is indicated for the prevention of cluster headaches, and it is actually the first-line prophylactic agent (SOR A). Oxygen and sumatriptan are first-line abortive therapies for cluster headaches (SOR A).

Question 7

94. Based on U.S. Preventive Services Task Force guidelines, screening for lung cancer with low-dose CT of the chest is indicated for which one of the following patients with a 30-pack-year smoking history?

A) A 50-year-old current smoker
B) An 85-year-old current smoker
C) A 60-year-old who quit smoking 10 years ago
D) A 75-year-old who quit smoking 20 years ago

Answer 7

Item 94
ANSWER: C
The U.S. Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults 55–80 years of age who have a 30-pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have lung surgery (B recommendation).

The risk of lung cancer increases with age and cumulative exposure to tobacco smoke and decreases with time since quitting smoking. The best evidence comes from the National Lung Screening Trial, which enrolled adults age 55–74 who had at least a 30-pack-year smoking history and were current smokers or had quit in the past 15 years. Screening with LDCT resulted in a 20% reduction in lung-cancer mortality among participants. Stratification of participants according to lung cancer risk showed that screening with LDCT prevented the greatest number of deaths from lung cancer among participants with the highest risk and prevented few deaths in the lowest-risk groups. Smoking cessation remains the most effective way to decrease the mortality and morbidity associated with lung cancer, however.

Question 8

93. A 21-year-old male comes to your office for a follow-up visit to discuss pharmacologic treatment for his acne. He has moderate inflammatory acne lesions with comedones and several papules and pustules, but few nodules. Multiple topical antibiotic therapies, in combination with benzoyl peroxide, have been minimally effective. He is currently using just topical benzoyl peroxide. You would like to prescribe an oral agent to add to his regimen.

Which one of the following would be the most effective oral medication to start at this time?

A) Amoxicillin
B) Ciprofloxacin (Cipro)
C) Minocycline (Minocin)
D) Prednisone

Answer 8

Item 93
ANSWER: C
Oral antibiotics are effective for the treatment of moderate to severe acne (SOR A). Combined treatment with benzoyl peroxide is recommended to reduce the risk of bacterial resistance (SOR C). Amoxicillin and ciprofloxacin are not recommended for acne treatment. Intralesional corticosteroid therapies have been tried for acne treatment, but long-term use of oral corticosteroids is not recommended.

Question 9

92. You test a patient’s muscle strength and find that his maximum performance consists of the ability to move with gravity neutralized. This qualifies as which grade of muscle strength, on a scale of 0 to 5?

A) 0 
B) 1 
C) 2 
D) 3 
E) 4

Answer 9

Item 92
ANSWER: C
Muscle strength is scored on a scale of 0 to 5. The inability to contract a muscle is scored as 0. Contraction without movement constitutes grade 1 strength. Movement with the effect of gravity neutralized is grade 2 strength, while movement against gravity only is grade 3 strength. Movement against gravity plus some additional resistance indicates grade 4 strength. Normal, or grade 5, strength is demonstrated by movement against substantial resistance.

Question 10

91. In patients who die from an opioid overdose, a second medication is often present that contributes to the patient’s death. Which one of the following additional medications is most likely to be found in conjunction with a fatal opioid overdose?

A) Acetaminophen
B) Antidepressants
C) Antipsychotics
D) Benzodiazepines
E) Muscle relaxants

Answer 10

Item 91
ANSWER: D
In 2010, opioid analgesics were implicated in 75% of pharmaceutical-related overdose deaths. Benzodiazepines were involved in 30% of these opioid analgesic–related deaths. Conversely, opioids were a factor in 77% of pharmaceutical overdose deaths that involved benzodiazepines.

Antidepressants are involved in less than half as many opioid deaths as benzodiazepines. Antipsychotics, acetaminophen, and muscle relaxants are implicated in opioid overdose deaths with far less frequency than benzodiazepines.

Question 11

90. A 55-year-old male has a 3-month history of chronic shortness of breath and dyspnea on exertion. His physical examination is unremarkable except for 1+ ankle edema bilaterally and a soft systolic murmur. A stress echocardiogram is normal. Pulmonary function tests are normal except for a low diffusing capacity of the lung for carbon monoxide (DLCO).

Which one of the following conditions should be considered in this patient?

A) Chronic pulmonary thromboembolism
B) Emphysema
C) Interstitial lung disease
D) Asthma
E) Hypersensitivity pneumonitis

Answer 11

Item 90
ANSWER: A
A diffusion capacity test assesses how well a tracer gas in inspired air can cross from the air into the blood. The diffusion capacity provides a general assessment of the air-blood interface. Reduced values are seen with severe interstitial fibrosis, or when the capillary surface has been compromised by vascular obstruction (pulmonary embolism) or is destroyed by emphysema. Chronic pulmonary embolism causes a low diffusing capacity of the lung for carbon monoxide (DLCO) with normal pulmonary function tests. Emphysema causes a low DLCO and an obstructive pattern on pulmonary function testing (PFT). Interstitial lung disease and hypersensitivity pneumonitis both cause a low DLCO with a restrictive pattern of PFTs. Patients with asthma may have an increased DLCO with an obstructive pattern, with reversibility after bronchodilator administration.

Question 12

89. A 55-year-old female has severe sepsis due to pyelonephritis. Her systolic blood pressure remains at 70 mm Hg despite antibiotics and adequate fluid resuscitation.

Which one of the following should be considered the vasopressor of first choice for this patient?

A) Dopamine
B) Epinephrine
C) Vasopressin (Pitressin)
D) Dobutamine
E) Norepinephrine (Levophed)

Answer 12

Item 89
ANSWER: E
Norepinephrine is considered to be the vasopressor of choice in this situation. It has mainly “-adrenergic effects with some B-adrenergic effects as well. While “-adrenergic agents increase mean arterial pressure, they decrease cardiac output. Norepinephrine’s B-adrenergic properties counteract the decrease in cardiac output, so there is an increase in blood pressure with little change in pulse rate or cardiac output.

Vasopressin may be useful in patients with cardiac arrest and ventricular fibrillation and may further improve hypotension when used with norepinephrine. Dobutamine is the inotropic agent of choice but has little effect on blood pressure. Epinephrine can increase the incidence of arrhythmias when compared with norepinephrine. Dopamine also increases arrhythmias when compared with norepinephrine and is associated with an increased 28-day death rate.

Question 13

88. Which one of the following strategies for preventing the spread of Clostridium difficile infection has been shown to be most effective?

A) Use of alcohol-based hand sanitizer
B) Handwashing with soap and water
C) Screening health care providers for the carrier state
D) Administration of probiotics to at-risk patients
E) Use of N95 masks and negative-pressure rooms

Answer 13

Item 88
ANSWER: B
Clostridium difficile infection (CDI) may be transmitted by direct contact with an infected patient, by contact with a contaminated environment, or by contact with a health care worker with transient hand colonization. Effective prevention efforts are essential to limit the spread from one patient to another in the hospital and other health care settings. Although alcohol-based hand antiseptics have been shown to increase compliance with hand hygiene and reduce the incidence of MRSA and VRE infections, alcohol does not kill the spore form of C. difficile and the use of these antiseptics does not reduce the incidence of CDI. There is insufficient data to support the widespread use of probiotics for prevention of CDI, and there is a potential risk of bloodstream infection with their use.

Health care workers rarely become colonized with C. difficile, and screening them has not been shown to affect nosocomial transmission rates. Handwashing with soap and water removes C. difficile from the hands of health care workers and remains the cornerstone of prevention efforts. Additional contact precautions such as the use of gloves and gowns may also be helpful. CDI is not transmitted by the respiratory route, so the use of respiratory isolation techniques is not helpful.

Question 14

87. A 57-year-old female on dialysis for end-stage renal disease develops chronic, severe generalized pain. Which one of the following opioids is preferred for management of her pain?

A) Codeine
B) Fentanyl
C) Hydrocodone
D) Morphine

Answer 14

Item 87
ANSWER: B
Fentanyl and methadone are the preferred opioids for use in patients with end-stage renal disease (SOR C). Fentanyl is metabolized in the liver and has no active metabolites. All of the other listed opioid medications have active metabolites that can accumulate in patients with renal failure, leading to serious side effects. These agents should be avoided in patients on dialysis.

Question 15

86. A 2-week-old female is brought to the office for a well child visit. The physical examination is completely normal except for a clunking sensation and feeling of movement when adducting the hip and applying posterior pressure.

Which one of the following would be the most appropriate next step?

A) Referral for orthopedic consultation
B) Reassurance only, and follow-up in 2 weeks
C) Triple diapering and follow-up in 2 weeks
D) A radiograph of the pelvis

Answer 15

Item 86
ANSWER: A
Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities. It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia.

Experts are divided as to whether hip subluxation can be merely observed during the newborn period, but if there is any question of a hip problem on examination by 2 weeks of age, the recommendation is to refer to a specialist for further testing and treatment. Studies show that these problems disappear by 1 week of age in 60% of cases, and by 2 months of age in 90% of cases. Triple diapering should not be used because it puts the hip joint in the wrong position and may aggravate the problem. Plain radiographs may be helpful after 4–6 months of age, but prior to that time the ossification centers are too immature to be seen.

Because the condition can be difficult to diagnose, and can result in significant problems, the current recommendation is to treat all children with developmental dysplasia of the hip. Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age. The American Academy of Pediatrics recommends ultrasound screening at 6 weeks for breech females, breech males (optional), and females with a positive family history of developmental dysplasia of the hip. Other countries have recommended universal screening, but a review of the literature has not shown that the benefits of early diagnosis through universal screening outweigh the risks and potential problems of overtreating.

Question 16

85. A 45-year-old female who is a new patient sees you for a well care visit. She requests all screening tests and procedures that are appropriate for her.

She is unmarried but has been in a monogamous relationship with a male partner for the past 10 years. She reports that she has never had an abnormal Papanicolaou (Pap) test result, but that when she had a Pap test last year she did not have a test for human papillomavirus (HPV). She also had normal findings on a mammogram 1 year ago. Her previous physician had been seeing her every 3 months to monitor her blood pressure, which has consistently been 135–140 mm Hg systolic and 85–90 mm Hg diastolic. She takes no antihypertensive medication, but has instituted dietary and lifestyle changes.

According to the U.S. Preventive Services Task Force, which one of the following screening
tests or procedures is now recommended for this patient?

A) A bimanual pelvic examination with CA-125 testing to screen for ovarian cancer

B) A Pap test with co-testing for HPV

C) Screening for Chlamydia

D) Screening for diabetes mellitus

E) Screening for colorectal cancer

Answer 16

Item 85
ANSWER: D
The U.S. Preventive Services Task Force recommends that asymptomatic adults with sustained blood pressure (treated or untreated) >135/80 mm Hg be screened for type 2 diabetes mellitus. Since this patient was screened 1 year ago for cervical cancer, and has no history of an abnormality, she does not require cytology again for another 2 years. If her Papanicolaou test 1 year ago had been combined with HPV testing the rescreening interval could be extended to 5 years if both were negative. Routine screening for ovarian cancer with bimanual examination, transvaginal ultrasonography, or CA-125 testing is not recommended. Chlamydia screening is recommended for high-risk sexually active women over 25 and for all sexually active women age younger than 25. Colorectal cancer screening should begin at age 50.

Question 17

84. A gynecologist requests a preoperative consultation on your patient, a 38-year-old white gravida 2 para 0 abortus 2 whom you referred for total abdominal hysterectomy for adenomatous endometrial hyperplasia.

The patient has been hospitalized twice for deep-vein thrombophlebitis in the past 2 years and had spontaneous second-trimester abortions at the ages of 34 and 36. Routine preoperative blood screening reveals the following:

Platelet count. . . . . . . . . . . . . . . . . . . . . . . 189,000/mm3
(N 150,000–400,000)
Prothrombintime. . . . . . . . . . . . . . . . . . . . . 12.0sec(N10.0–12.5)
INR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1
Activated partial thromboplastin time. . . .42 sec (N 25–35)

There is no family history of bleeding disorders and the evaluation is otherwise completely normal.

A repeat activated partial thromboplastin time with a 1:1 mixture of normal plasma does not correct to normal.

The most likely diagnosis is

A) protein C deficiency
B) antiphospholipid antibody syndrome
C) factor VIII deficiency (hemophilia A)
D) chronic liver disease
E) von Willebrand disease

Answer 17

Item 84
ANSWER: B
The most common inhibitor discovered during the evaluation of an elevated aPTT is an antiphospholipid antibody. Antiphospholipid antibody syndrome is characterized by venous or arterial thromboembolism and recurrent spontaneous abortion, often in the second trimester, due to placental infarction. Protein C deficiency is associated with recurrent deep vein thrombophlebitis, but does not cause elevation of aPTT. Hemophilia A is associated with an elevated aPTT which corrects with the addition of normal plasma. In chronic liver disease one would expect an elevation of the prothrombin time also. Von Willebrand disease is not associated with thrombophlebitis or recurrent abortion.

Question 18

83. A new serum marker has been developed for the diagnosis of pulmonary embolism. The test has a likelihood ratio of 1.

Which one of the following conclusions can be made from this information?

A) The test can confirm pulmonary embolism
B) The test rules out pulmonary embolism
C) The test can neither confirm nor rule out pulmonary embolism
D) The likelihood ratio does not determine how well a test performs

Answer 18

Item 83
ANSWER: C
The likelihood ratio (LR) is the ratio of the probability of a specific test result in people who have a particular disease to the probability in people who do not. LRs correspond to the clinical impression of how well a test rules in or rules out a given disease. A test with an LR of 1.0 indicates that it does not change the probability of disease. The higher above 1 the LR is, the more likely it is that the disease is present (an LR >10 is considered good). Conversely, the lower the LR is below 1, the more likely it is that the disease is not present (an LR less than 0.1 is considered good). Likelihood ratios are alternative statistics for summarizing diagnostic accuracy, and have several particularly powerful properties that make them more useful clinically than other statistics.

Question 19

82. An 86-year-old female nursing-home resident has type 2 diabetes mellitus, chronic diastolic heart failure, chronic kidney disease, advanced osteoarthritis, hypertension, Alzheimer’s disease, and other comorbidities. She requires assistance with dressing, bathing, and feeding.

For this patient, the American Geriatrics Society recommends a hemoglobin A1c goal of

A) less than 7.0%
B) less than 8.0%
C) less than 8.5%
D) less than 9.0%
E) less than 9.5%

Answer 19

Item 82
ANSWER: C
The American Geriatrics Society consensus report for considering treatment goals for glycemia recommends a hemoglobin A1c goal of less than 8.5% for individuals with very complex health problems or poor health. This includes individuals in long-term care and those with end-stage chronic illnesses, moderate to severe cognitive impairment, or more than two activity of daily living (ADL) dependencies. A hemoglobin A1c less than 8.5% equates to an estimated average glucose level of approximately 200 mg/dL. Looser glycemic targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.

Question 20

81. A 53-year-old white female with chronic hepatitis C is concerned about ulcers in her mouth. She is not currently receiving therapy. Your examination reveals several ulcers involving the buccal mucosa. The patient also points out a number of pruritic, reddish-purple plaques on her wrists, ankles, and back. Laboratory studies are within normal limits except for mildly elevated transaminases.

Which one of the following is the most likely diagnosis?

A) Behçet’s syndrome
B) Lichen planus
C) Aphthous stomatitis
D) Herpetic stomatitis
E) HIV infection

Answer 20

Item 81
ANSWER: B
Lichen planus is an idiopathic inflammatory disease affecting the skin and oral mucosa. The characteristic violaceous, polygonal papules may be intensely itchy. There is a significant association between lichen planus and hepatitis C virus infection.

Question 21

80. An 18-month-old female with atopic dermatitis is brought to your office. She has recently had a flare-up of her condition that has been slow to resolve, and the mother says the child scratches “constantly” despite daily use of emollients.

Which one of the following would be the best treatment?

A) A topical mild-potency corticosteroid
B) Topical pimecrolimus (Elidel)
C) Oral diphenhydramine (Benadryl)
D) Oral cetirizine (Zyrtec)
E) Probiotics

Answer 21

Item 80
ANSWER: A
Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups. Topical calcineuron inhibitors such as pimecrolimus are a second-line therapy, but carry a warning of a possible link to lymphomas and skin malignancies and are not recommended for children under 2 years of age. Oral antihistamines are not effective for the pruritus associated with atopic dermatitis. Probiotic use is not supported by available evidence.

Question 22

79. A 21-year-old female sees you because of a depressed mood since the birth of her son 2 months ago. She is breastfeeding, and her baby is doing well. She reports no difficulties sleeping, other than what is to be expected when caring for a newborn. She denies any suicidal or homicidal ideation and has never had thoughts about hurting the baby. She has a history of depression 2 years ago that was associated with starting college and feeling very isolated in the dormitory. She began taking sertraline (Zoloft), changed her schedule, and spent more time exercising. Within 6 months her depression resolved and she stopped the medication. She reports this current depression feels worse than her previous depression.

Which one of the following would be the most appropriate medication for this patient?

A) Amitriptyline
B) Diazepam (Valium)
C) Phenytoin
D) Sertraline
E) Zolpidem (Ambien)

Answer 22

Item 79
ANSWER: D
SSRIs are the most commonly used medications for postpartum depression. They have fewer side effects and are considered safer than tricyclic antidepressants, especially in depressed women who may be at increased risk for medication overdose (SOR C). In one study, infant serum levels of sertraline and paroxetine were undetectable. It is also recommended that a woman with postpartum depression be started on a medication that she had taken previously with a good response, unless there is evidence of potential harm to her infant (SOR C).

Tricyclic antidepressants are excreted into breast milk and there is some concern regarding potential toxicity to the newborn. Phenytoin, diazepam, and zolpidem are not antidepressants. Phenytoin and diazepam are Category D for use in pregnant women. Diazepam is potentially toxic to infants and can accumulate in breastfed infants, and it is not recommended for lactating women (SOR C). Zolpidem is category B in pregnancy and probably acceptable for use in lactating women if clinically indicated.

Question 23

78. A 45-year-old female has been admitted to the hospital for an episode of acute diverticulitis. Which one of the following features would most strongly suggest a need for surgical intervention?

A) A previous admission for diverticulitis in the last 12 months
B) Pain uncontrolled by oral analgesics
C) A microperforation seen on CT at the site of the diverticulitis
D) A 4-cm simple abscess at the site of the diverticulitis
E) The presence of generalized peritonitis

Answer 23

Item 78
ANSWER: E
Acute diverticulitis can be treated using oral antibiotics on an outpatient basis in 90% of cases. In fact, there is good evidence that those with uncomplicated diverticulitis (no signs of abscess, fistula, phlegmon, obstruction, bleeding, or perforation) can be treated without the use of antibiotics, using only bowel rest and close follow-up. Among patients who require hospitalization, it is estimated that less than 10% of cases will require surgical intervention. Thus, the majority of patients hospitalized with this condition, even those with complicated diverticulitis, will respond well to bowel rest and intravenous antibiotics.
Indications for surgery include generalized peritonitis, unconfined perforation, uncontrolled sepsis, an undrainable abscess, and failure of conservative management. CT-guided percutaneous drainage of an accessible abscess is a well-proven treatment to avoid the use of open surgery. Prevention of future episodes of diverticulitis increasingly revolves around the use of daily oral medications. Some experts recommend considering surgery to remove a section of bowel after a patient’s third admission for diverticulitis.

Question 24

77. Which one of the following is the best exercise to improve function in older adults living in nursing homes?

A) Swimming
B) Walking
C) Stretching
D) Stationary bicycling
E) Resistance training

Answer 24

Item 77
ANSWER: E
Many types of exercise programs are beneficial for older adults, including simply walking for 30 minutes three times a week. However, a meta-analysis of progressive resistance training programs in nursing homes showed that there were significant improvements in muscle strength, chair-to-stand time, stair climbing, gait speed, and balance. This is seen even in those with advanced age, disabilities, chronic diseases, or extremely sedentary lifestyles.

Question 25

76. A 48-year-old female sees you for routine follow-up. She was diagnosed with type 2 diabetes mellitus 2 years ago and has been treated with metformin (Glucophage), 850 mg orally 3 times daily, and glipizide (Glucotrol XL), 20 mg orally daily, along with diet and exercise. Her other medical problems include hypertension and obesity. She has no known cardiovascular disease or microvascular complications. She came in for laboratory testing yesterday, and her hemoglobin A1c is 8.0% (N less than 5.7%).

Which one of the following medications would help with both glycemic control and weight loss
for this patient?

A) Exenatide (Byetta)
B) Pioglitazone (Actos)
C) Sitagliptin (Januvia)
D) Insulin

Answer 25

Item 76
ANSWER: A
Given the information about this patient, such as her relatively recent diagnosis, her age, and her lack of macro- or microvascular complications, a more strict hemoglobin A1c goal is indicated. There are several oral and injectable medicines that are reasonable choices in this case. Exenatide is an injectable GLP-1 agonist that is associated with weight loss. Pioglitazone is also effective but is associated with fluid retention rather than weight loss. Sitagliptin is a dipeptidyl peptidase IV (DPP-IV) inhibitor that may be a reasonable option in this case, but is not associated with weight loss. Insulin, either basal only, mixed, or basal-bolus regimens, may also be the best option for the patient described, but it does cause weight gain. Cost is another major consideration in treatment decisions, but more information would be needed to address this issue.

Question 26

75. A 45-year-old female had myalgias, a sore throat, and a fever 2 weeks ago. She now has anterior neck tenderness and swelling, with pain radiating up to her ears. Your examination reveals a tender goiter.

Which one of the following would support a diagnosis of subacute granulomatous thyroiditis?

A) Pretibial myxedema
B) Exophthalmos
C) Multiple nodules on ultrasonography
D) Low radioactive iodine uptake (less than 5%)

Answer 26

Item 75
ANSWER: D
Subacute granulomatous thyroiditis is the most common cause of thyroid pain. Free T4 is elevated early in the disease, as it is in Graves disease; however, later in the disease T4 becomes depressed and then returns to normal as the disease resolves. Pretibial myxedema, exophthalmos, and a thyroid thrill or bruit can all be found in Graves disease, but are not associated with subacute granulomatous thyroiditis. Multiple nodules on ultrasonography suggests multinodular goiter rather than subacute granulomatous thyroiditis. Patients with subacute granulomatous thyroiditis will have a low radioactive iodine uptake (RAIU) at 24 hours, but patients with Graves disease will have an elevated RAIU (SOR C).

Question 27

74. A 36-year-old white female calls you to report that she removed a small blood-engorged tick from her upper arm the previous evening, 3 days after returning from a camping trip in the mountains of New Hampshire.

Which one of the following would you recommend?

A) A single 200-mg dose of doxycycline
B) Doxycycline, 100 mg twice daily for 7 days
C) Azithromycin (Zithromax), 500 mg daily for 7 days
D) Topical mupirocin ointment (Bactroban), twice daily for 3 days
E) No treatment unless she develops the typical erythema migrans rash

Answer 27

Item 74
ANSWER: A
In areas where there is at least a 20% rate of tick infection, 200 mg of doxycycline within 72 hours of tick removal is appropriate as prophylaxis for Lyme disease if the tick is engorged or is suspected to have been attached for at least 36 hours. The Northeast and Upper Midwest are the most endemic areas. The other oral antibiotics listed are appropriate for cases of acute erythema migrans and suspected infection. Watchful waiting is not recommended, and there is no evidence for treatment with topical antibiotics alone (SOR C).

Question 28

73. An 18-month-old male is brought to your office by his mother. The patient is tugging at both ears and has a temperature of 39.0°C (102.2°F). You diagnose bilateral acute otitis media for the third time in the last 6 months. The most recent infection was 3 weeks ago and resolution of the infection was documented after 10 days of treatment with amoxicillin.

Which one of the following antibiotic regimens would be most appropriate at this time?

A) Amoxicillin, 45 mg/kg/day for 10 days

B) Amoxicillin, 90 mg/kg/day for 10 days

C) Amoxicillin, 90 mg/kg/day for 10 days followed by prophylactic treatment with
amoxicillin for 6 months

D) Amoxicillin/clavulanate (Augmentin), 90 mg/kg/day for 10 days

E) Amoxicillin/clavulanate, 90 mg/kg/day for 10 days followed by prophylactic treatment with amoxicillin for 6 months

Answer 28

Item 73
ANSWER: D
Although high-dose amoxicillin (90 mg/kg/day) is recommended as the antibiotic of choice for acute otitis media (AOM) in the nonallergic patient, amoxicillin/clavulanate is recommended if a child has received antibiotic therapy in the previous 30 days. Prophylactic antibiotics are not recommended, as harms outweigh benefits. Tympanostomy tubes are an option if a child has had three episodes of AOM in the past 6 months or four episodes in the past year with at least one episode in the past 6 months.

Question 29

72. A 62-year-old male has a 1-month history of intermittent vomiting, early satiety, and a weight loss of 4 kg (9 lb). Initially he had diarrhea but it has resolved. He does not have abdominal pain or bloody stools. He says that over-the-counter famotidine (Pepcid) has relieved the symptoms somewhat.

Which one of the following would be most appropriate at this point?

A) Abdominal radiographs
B) Abdominal ultrasonography
C) Esophagogastroduodenoscopy
D) Famotidine at a higher dosage
E) A proton pump inhibitor

Answer 29

Item 72
ANSWER: C
This patient has red flag findings of older age and weight loss with chronic vomiting and is at risk for a gastrointestinal malignancy. He should be referred for esophagogastroduodenoscopy (EGD). Abdominal ultrasonography or radiographs would not be necessary at this time. A proton pump inhibitor or H2-blocker can be prescribed but should not delay referral for EGD.

Question 30

71. A 75-year-old otherwise healthy white female states that she has passed out three times in the last month during her daily brisk walk. Which one of the following is the most likely cause of her syncope?

A) Vasovagal syncope
B) Transient ischemic attack
C) Orthostatic hypotension
D) Atrial myxoma
E) Aortic stenosis

Answer 30

Item 71
ANSWER: E
Syncope with exercise is a manifestation of organic heart disease in which cardiac output is fixed and does not rise (or even fall) with exertion. Syncope, commonly occurring with exertion, is reported in up to 42% of patients with severe aortic stenosis. Vasovagal syncope is associated with unpleasant stimuli or physiologic conditions, including sights, sounds, smells, sudden pain, sustained upright posture, heat, hunger, and acute blood loss. Transient ischemic attacks are not related to exertion. Orthostatic hypotension is associated with changing from a sitting or lying position to an upright position. Atrial myxoma is associated with syncope related to changes in position, such as bending, lying down from a seated position, or turning over in bed.

Question 31

70. A 32-year-old primigravida at 36 weeks gestation complains of headaches. She denies vaginal bleeding, leakage of fluid, and contractions, and the fetus is moving normally. Her blood pressure is 155/100 mm Hg and a urinalysis shows 4+ protein. The rest of her examination is normal and a cervical examination shows 1 cm of dilation, 50% effacement, a soft consistency, anterior position, and –2 vertex station. Results of a preeclampsia panel are all in the normal range.

Which one of the following is the most appropriate management for this patient?

A) Start labetalol (Trandate) and discharge home on bed rest with close follow-up

B) Start magnesium sulfate and induce labor now

C) Start magnesium sulfate, administer corticosteroids, and induce labor in 48 hours

D) Start magnesium sulfate, lower blood pressure to 140/90 mm Hg, and induce labor at 37 weeks gestation

E) Arrange for urgent cesarean section

Answer 31

Item 70
ANSWER: B
This patient likely has severe preeclampsia based on her elevated blood pressure with 4+ protein on her urinalysis. Patients with severe preeclampsia near term should be placed on magnesium sulfate to prevent seizures, and labor should be induced immediately. An urgent cesarean section is not necessary. Corticosteroids have not been shown to improve neonatal outcomes when given after 34 weeks gestation. Elevated blood pressures can be managed with hydralazine and labetalol. Normalizing blood pressure is not recommended, but these drugs should be used when blood pressure is over 160/105 mm Hg.

Question 32

69. A 4-year-old male sees you for pre-kindergarten screening. On corneal light reflex testing, the light reflex in the patient’s right eye is in the center of the pupil. In the left eye it is located below the pupil, over the inferior-lateral portion of the iris.

This clinical finding is associated with a congenital palsy of which one of the following cranial nerves?

A) Third 
B) Fourth 
C) Fifth
D) Sixth 
E) Seventh

Answer 32

Item 69
ANSWER: B
In a corneal light reflex test, the patient’s attention is attracted to a target while a light is directed at the eyes. In normally aligned eyes the light reflex will be located in the center of each pupil. In patients with esotropia the reflex will be over the lateral portion of the iris in the affected eye. In exotropia the light reflex is over the medial iris, in hypertropia it is over the inferior iris, and in hypotropia it is over the superior iris. The finding observed in this child, hypertropia, will occur with a congenital palsy involving the superior oblique muscle, which is innervated by the fourth cranial nerve.

Question 33

68. According to the Joint Commission’s sentinel event program, the most common root cause of serious medical errors is a deficiency of

A) competency and credentialing
B) staffing
C) communication
D) leadership
E) organization culture

Answer 33

Item 68
ANSWER: C
According to The Joint Commission’s sentinel event program, communication problems are the most common root cause of serious medical errors. Strategies such as the implementation of structured and standardized handoffs are an example of improving communication among members of the health care team, thereby helping to reduce errors.

Question 34

67. Which one of the following therapeutic interventions improves outcomes in adults with acute respiratory distress syndrome (ARDS)?

A) Early initiation of antibiotics
B) Surfactant therapy
C) Pulmonary artery catheterization
D) Aggressive intravenous fluid resuscitation
E) Starting mechanical ventilation with lower tidal volumes

Answer 34

Item 67
ANSWER: E
In patients with acute respiratory distress syndrome (ARDS), starting mechanical ventilation with lower tidal volumes of 6 mL/kg is superior to starting with traditional tidal volumes of 10–14 mL/kg (SOR A). Conservative fluid therapy is recommended in patients with ARDS, as this is associated with a decrease in the number of days on the ventilator and in the intensive-care unit (SOR B). Pulmonary artery catheters are not recommended for routine management of ARDS (SOR A). Surfactant therapy does not improve mortality in adults with ARDS (SOR A), and antibiotics are not an effective treatment.

Question 35

66. An 80-year-old male presents with a 10-day history of intermittent colicky abdominal pain. The pain is low and central and seems to be worse after eating. He has no associated fever or vomiting but does feel nauseated when the pain is present. He says that prior to this episode he had hard stools once or twice a week that were difficult to pass. For the past several days he has had only watery stools, several times a day.

On examination there is fullness in his left lower quadrant with nonspecific tenderness diffusely and no guarding or rebound. A urine dipstick is normal.

Which one of the following is the most likely diagnosis?

A) Viral gastroenteritis
B) Acute colitis
C) Constipation
D) Urinary tract infection
E) Nephrolithiasis

Answer 35

Item 66
ANSWER: C
The Rome criteria define constipation as the presence of two or more of the following: straining on defecation, hard stools, incomplete evacuation, or less than three bowel movements per week. This patient has multiple symptoms on this list. The presence of watery bowel movements does not rule out the diagnosis of constipation, as it is common for liquid stool to pass an obstructive source.

Question 36

65. A 2-year-old female is brought to the urgent care center with a fever and cough. Her symptoms started suddenly a few hours ago with a runny nose and fever to 101°F. On examination the child is crying and has a persistent barking cough but has no stridor or significant respiratory distress. Her lungs are clear to auscultation. Her skin is warm, pink, and well perfused, and her oxygen saturation is 99% on room air. A chest radiograph is normal.

Which one of the following treatments has been shown to improve outcomes for this problem?

A) Humidified air
B) Nebulized albuterol (Proventil, Ventolin)
C) Oral azithromycin (Zithromax)
D) Oral dexamethasone
E) Oxygen therapy

Answer 36

Item 65
ANSWER: D
This patient presents with a typical case of mild to moderate croup. This is a viral infection that results in swelling in the larynx. It rarely is severe enough to cause respiratory collapse or require intubation and must be differentiated from more severe conditions such as epiglottitis, retropharyngeal abscess, or pneumonia. There is no reason to treat this viral infection with an antibiotic. The condition is usually benign and self-limiting, with the worst symptoms occurring at night. Cool and/or humidified air has traditionally been recommended, but studies have not confirmed any significant benefit from these interventions. Since this child is not in respiratory distress and oxygenation is normal, supplemental oxygen therapy is not indicated. Studies have confirmed the benefits of treating croup with a single dose of either an oral or intramuscular corticosteroid. Specifically, dexamethasone is recommended due to its 72-hour length of effect. Inhaled racemic epinephrine has been shown to reduce the need for intubation in cases of moderate to severe croup. Albuterol, however, is not indicated.

Question 37

64. A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation causes pain over the lateral fifth metatarsal. The pain is also reproduced when he jumps on the affected leg. When you ask about his shoes he tells you he bought them several years ago.

Which one of the following is the most likely diagnosis?

A) Ligamentous sprain of the arch
B) Stress fracture
C) Plantar fasciitis
D) Osteoarthritis of the metatarsal joint

Answer 37

Item 64
ANSWER: B
Running injuries are primarily caused by overuse due to training errors. Runners should be instructed to increase their mileage gradually. A stress fracture causes localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg. Plantar fasciitis causes burning pain in the heel and there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.

Question 38

63. A 20-year-old offensive lineman who plays football for the small college in your town presents to your office at midseason with pain in his right groin. He describes it as a burning, aching sensation that gets worse when he coughs or strains during a bowel movement, and when he is required to block opponents or push against the blocking sled in practice.

As part of the physical examination, you have the patient stand, and you insert your finger into the inguinal canal and follow the spermatic cord to the internal inguinal ring. When you reach the internal ring the patient reports discomfort. When you ask him to cough and strain the pain increases and you feel an impulse or bulge at the tip of your finger. The remainder of his physical examination is normal.

This patient’s history and examination findings are most consistent with which one of the following diagnoses?

A) Athletic pubalgia (sports hernia)
B) Osteitis pubis
C) Adductor muscle tendinopathy
D) Ilioinguinal nerve entrapment
E) Inguinal hernia

Answer 38

Item 63
ANSWER: E
This patient’s history, along with the bulge/impulse detected on physical examination when he strained or coughed, is most consistent with the diagnosis of inguinal hernia. A “sports hernia” is not a true hernia, but rather a tearing of tissue fibers. The patient often presents with symptoms consistent with a hernia, but without evidence on physical examination. Pain along the symphysis pubis would suggest osteitis pubis, and pain along the adductor tendons would suggest adductor tendinopathy. Ilioinguinal nerve entrapment syndrome is an abdominal muscular pain syndrome characterized by the clinical triad of muscle-type iliac fossa pain with a characteristic radiation pattern, altered sensory perception in the ilioinguinal nerve cutaneous innervation area, and a well-circumscribed trigger point medial to and below the anterosuperior iliac spine.

Question 39

62. An asymptomatic 56-year-old male has an echocardiogram that demonstrates trivial mitral regurgitation. Which one of the following is the recommended follow-up for this patient if he remains asymptomatic?

A) No repeat echocardiography
B) Repeat echocardiography in 1 year
C) Repeat echocardiography in 2 years
D) Repeat echocardiography in 5 years
E) Repeat echocardiography in 10 years

Answer 39

Item 62
ANSWER: A
The American Society of Echocardiography recommends that physicians NOT order follow-up or serial echocardiograms for surveillance after a finding of trace valvular regurgitation on an initial echocardiogram (SOR C). Trace mitral, tricuspid, and pulmonic regurgitation can be detected in 70%–90% of normal individuals and has no adverse clinical implications. The clinical significance of a small amount of aortic regurgitation with an otherwise normal echocardiographic study is unknown.

Question 40

61. A 36-year-old male with a history of complex regional pain syndrome has been on oxycodone (OxyContin) for the past 5 years. His pain is well controlled.

Which one of the following side effects is most likely to occur with long-term chronic use of opioids?

A) Diarrhea
B) Sedation
C) Hypoalgesia
D) Respiratory depression
E) Hypogonadism

Answer 40

Item 61
ANSWER: E
Hypogonadism is an often underrecognized and undertreated side effect of long-term opioid therapy. It is more often seen in men and in patients receiving larger doses of opioids, including intrathecally. Typical symptoms include decreased libido, erectile dysfunction, amenorrhea, or fatigue.

Constipation is not uncommon in patients on chronic opioid therapy, especially if they are elderly, have limited mobility, or are concurrently using other constipating medications. Sedation can occur in the first few weeks after starting therapy but usually tapers off. Hyperalgesia (not hypoalgesia) and allodynia are other side effects resulting from chronic opioid therapy. Respiratory depression is infrequent (SOR C).

Question 41

60. A 4-month-old female is brought to your office by her parents for a 3-day history of fever up to 101.7°F (38.7°C). She is fussy and her oral intake is down. She has no rash, no emesis, and no diarrhea. Her urine output is normal. She is in day care 3 days a week.

On examination she is alert but fussy. Her rectal temperature is 38.4°C (101.1°F). The examination is otherwise normal and there are no focal findings of infection. The parents are reliable and you choose to manage the baby as an outpatient.

Which one of the following tests is most likely to be helpful in this situation?

A) A CBC with manual differential
B) A urinalysis and urine culture
C) A chest radiograph
D) C-reactive protein
E) A lumbar puncture

Answer 41

Item 60
ANSWER: B
The most common causes of serious bacterial infection in children 3–36 months of age are pneumonia and urinary tract infection. In children without an obvious source of infection, the urinalysis and culture are key tests in the evaluation. A valid urine sample should be obtained in all children under the age of 2 with a fever of unknown source. The sample should be obtained through catheterization or suprapubic aspiration. If the patient is toilet trained a clean-catch urine sample is acceptable (SOR C). C-reactive protein is currently under investigation for its utility in detecting serious infection in young children. It is thought to have a greater predictive value than WBC counts but is not yet standardized for common use. A CBC with differential is most useful in neonates but is not as helpful in older infants for detecting serious infection. It is recommended for hospitalized patients but not for those managed as outpatients (SOR C).

A chest radiograph is indicated for children with an abnormal respiratory examination or respiratory symptoms. It is also recommended for children older than 1 month of age with a fever >39°C (102°F) and a WBC count >20,000/mm3. A lumbar puncture is indicated for infants with meningeal signs such as focal neurologic findings, petechiae, or nuchal rigidity.

Question 42

59. Which one of the following is recommended with regard to the use of osteoporosis medications in elderly patients?

A) Substitution of denosumab (Prolia) for bisphosphonates in patients planning extensive dental work

B) Use of denosumab in patients at increased risk for infection

C) Use of denosumab rather than bisphosphonates in patients with class III or IV renal dysfunction

D) Continuous use of bisphosphonates for 10 years or more

Answer 42

Item 59
ANSWER: C
The use of medications for osteoporosis is associated with various side effects, some of which have only recently been recognized. Denosumab and bisphosphonates have similar, albeit low, risks for jaw osteonecrosis. Bisphosphonates should not be used in patients with a creatinine clearance less than 35 mL/min/1.73 m2, but denosumab is not cleared by the kidneys and is safe in patients with chronic kidney disease. The use of bisphosphonates for more than 5 years can increase the risk of atypical fractures and a holiday from the drug is recommended after either 3 or 5 years, depending on the drug used.

Question 43

58. A 53-year-old obese female presents with left calf swelling and tenderness. Using the Wells criteria you determine that she is at intermediate risk for deep vein thrombosis.

Which one of the following is the most appropriate next step in the evaluation and treatment of this patient?

A) Anticoagulation
B) D-dimer assessment
C) Compression ultrasonography
D) Impedance plethysmography
E) Contrast venography

Answer 43

Item 58
ANSWER: C
In patients at intermediate to high risk for deep vein thrombosis, compression ultrasonography is the initial diagnostic test of choice. In low-risk patients, a negative D-dimer has a high enough negative predictive value to essentially rule out deep vein thrombosis. It is not sensitive or specific enough for evaluating intermediate-risk patients. Initiating treatment based on pretest probability would be inappropriate. Impedance plethysmography is not readily available, and contrast venography is too invasive to be used routinely.

Question 44

57. Which one of the following is a risk factor for prolonged recovery from a sports-associated concussion?

A) Blurred vision
B) Headache lasting longer than 60 hours
C) Amnesia for the injury
D) Loss of consciousness at the time of injury
E) Convulsions following the injury

Answer 44

Item 57
ANSWER: B
The majority of symptoms associated with sports-related concussions resolve within 72 hours of injury. However, some concussions result in prolonged recovery periods. Risk factors associated with a prolonged recovery include headaches lasting 60 hours or more, self-reported fatigue or fogginess, and four or more symptoms at the onset of injury (SOR B). Loss of consciousness and amnesia have not been found to be related to recovery time. Convulsions associated with the injury are benign and do not affect prognosis. Nausea is one of the symptoms of concussion, but by itself is not a risk factor for prolonged recovery.

Question 45

56. In a patient with symptoms of thyrotoxicosis and elevated free T4, the presence of thyroid TSH receptor site antibodies would indicate which one of the following as the cause of thyroid gland enlargement?

A) Toxic multinodular goiter
B) Toxic adenoma
C) Hashimoto’s (lymphadenoid) thyroiditis
D) Subacute (giant cell) thyroiditis
E) Graves disease

Answer 45

Item 56
ANSWER: E
When there is a question about the cause of goiter and thyrotoxicosis, the presence of TSH receptor immunoglobulins indicates Graves disease. The prevalence of specific forms of TSH receptor site antibodies can distinguish Graves disease from Hashimoto’s disease. Both are autoimmune diseases, but in Graves disease there is a predominance of TSH receptor antibodies. In Hashimoto’s disease TSH receptor–blocking antibodies are more predominant. These immunoglobulins tend to disappear with therapy.

Question 46

55. A decrease in which one of the following could be expected from long-term use of postmenopausal estrogen plus progesterone?

A) Ischemic heart disease
B) Dementia
C) All-cause mortality
D) Breast cancer
E) Hip fracture

Answer 46

Item 55
ANSWER: E
While hormonal therapy was initially used to treat postmenopausal vasomotor symptoms, it was also believed to prevent disease. Based on retrospective studies, a decrease in ischemic heart disease and dementia was suspected. The Women’s Health Initiative trials, first undertaken in the 1990s, showed that this was unfortunately not the case, and that hormone therapy actually increases the risk for coronary heart disease, stroke, breast cancer, gallbladder disease, dementia, and venous thrombosis, particularly in older women. A decrease in fractures was demonstrated, however, along with some other health benefits, such as a reduced risk of endometrial cancer.

Question 47

54. A 35-year-old female with a history of chronic abdominal pain and diarrhea develops tender red nodules on her shins. These findings are most consistent with which one of the following?

A) Celiac disease
B) Crohn’s disease
C) Diverticular disease
D) Irritable bowel syndrome
E) Clostridium difficile colitis

Answer 47

Item 54
ANSWER: B
Unlike the other conditions listed, Crohn’s disease is associated with many extragastrointestinal conditions: erythema nodosum (as with this patient), anemia, inflammatory arthropathies, uveitis, and venous thromboembolism (level of evidence 3).

Question 48

53. A 45-year-old male with no known medical problems sees you for a general physical examination. Which one of the following screening measures is recommended by the U.S. Preventive Services Task Force for this patient?

A) A fasting lipid profile
B) Colorectal cancer screening
C) Abdominal aortic aneurysm screening
D) Testicular examination
E) Prostate-specific antigen (PSA) testing

Answer 48

Item 53
ANSWER: A
The U.S. Preventive Services Task Force recommends that all men 35 years of age and older be screened for dyslipidemia (evidence rating A). Men who are 20–35 years of age should be screened only if they have cardiovascular risk factors (evidence rating B). Prostate-specific antigen (PSA) testing should not be performed at any age because the harms outweigh the benefits (evidence rating D). Colorectal cancer screening should begin at age 50 for men of average risk (evidence rating A). Abdominal aortic aneurysm (AAA) screening once by ultrasonography is recommended for men age 65–75 with a family history of AAA, and for those who have smoked at least 100 cigarettes in their lifetime (evidence rating B). Testicular examinations, either by self-examination or clinical screening, should not be performed routinely (evidence rating D).

Question 49

52. Blood pressure classification in children is based on
A) sex, weight, and height
B) sex, weight, and age
C) sex, height, and age
D) weight, height, and age

Answer 49

Item 52
ANSWER: C
Blood pressure in children should be measured with an appropriate size cuff. Blood pressure standards are based on age, sex, and height, and provide a precise classification of blood pressure according to body size. Blood pressure tables for children now include the 50th, 90th, 95th, and 99th percentiles by age, sex, and height (SOR A).

Question 50

51. A 25-year-old female kindergarten teacher comes to your office for evaluation of a cough she has had for 2 weeks. The preceding week she had symptoms of rhinorrhea, mild malaise, low-grade fever, and lacrimation. She reports that episodes of coughing are so severe that vomiting is induced. She was evaluated at a walk-in clinic 1 week ago and was diagnosed with bronchitis. Treatment with hydrocodone cough syrup and amoxicillin has not helped. On examination she has mild rhinorrhea and injected conjunctivae, but her lungs are clear. A chest radiograph is normal and her laboratory results reveal a mild lymphocytosis.

Which one of the following is the most appropriate next step in the management of this patient?

A) Corticosteroid therapy
B) A sputum culture
C) A nasopharyngeal culture and polymerase chain reaction testing
D) Direct fluorescent antibody testing
E) Serologic testing

Answer 50

Item 51
ANSWER: C
Whooping cough has reemerged over the past few years. The initial catarrhal stage is manifested by nonspecific symptoms similar to those of a viral upper respiratory illness. This stage is usually 1–2 weeks in duration, and the patient is highly contagious. The paroxysmal stage is manifested by severe coughing spells that occur in paroxysms and may be followed by the inspiratory whoop (much more likely in children). Post-tussive emesis is another classic sign. There are no characteristic findings on examination other than signs induced by extreme coughing. The CDC recommends both a nasopharyngeal culture and polymerase chain reaction testing to confirm the diagnosis. Serologic testing is useful only in research settings, and direct fluorescent antibody testing is not recommended. Azithromycin should be used as initial therapy, but this is to decrease transmission of the illness and does not improve symptoms.